Healthcare decision makers in search of reliable information that compares health interventions increasingly turn to systematic reviews for the best summary of the evidence. Systematic reviews ...identify, select, assess, and synthesize the findings of similar but separate studies, and can help clarify what is known and not known about the potential benefits and harms of drugs, devices, and other healthcare services. Systematic reviews can be helpful for clinicians who want to integrate research findings into their daily practices, for patients to make well-informed choices about their own care, for professional medical societies and other organizations that develop clinical practice guidelines.
Too often systematic reviews are of uncertain or poor quality. There are no universally accepted standards for developing systematic reviews leading to variability in how conflicts of interest and biases are handled, how evidence is appraised, and the overall scientific rigor of the process.
In Finding What Works in Health Care the Institute of Medicine (IOM) recommends 21 standards for developing high-quality systematic reviews of comparative effectiveness research. The standards address the entire systematic review process from the initial steps of formulating the topic and building the review team to producing a detailed final report that synthesizes what the evidence shows and where knowledge gaps remain.
Finding What Works in Health Care also proposes a framework for improving the quality of the science underpinning systematic reviews. This book will serve as a vital resource for both sponsors and producers of systematic reviews of comparative effectiveness research.
The value of integrated team delivery models is not firmly established.
To evaluate the association of receiving primary care in integrated team-based care (TBC) practices vs traditional practice ...management (TPM) practices (usual care) with patient outcomes, health care utilization, and costs.
A retrospective, longitudinal, cohort study to assess the association of integrating physical and mental health over time in TBC practices with patient outcomes and costs.
Adult patients (aged ≥18 years) who received primary care at 113 unique Intermountain Healthcare Medical Group primary care practices from 2003 through 2005 and had yearly encounters with Intermountain Healthcare through 2013, including some patients who received care in both TBC and TPM practices.
Receipt of primary care in TBC practices compared with TPM practices for patients treated in internal medicine, family practice, and geriatrics practices.
Outcomes included 7 quality measures, 6 health care utilization measures, payments to the delivery system, and program investment costs.
During the study period (January 2010-December 2013), 113,452 unique patients (mean age, 56.1 years; women, 58.9%) accounted for 163,226 person-years of exposure in 27 TBC practices and 171,915 person-years in 75 TPM practices. Patients treated in TBC practices compared with those treated in TPM practices had higher rates of active depression screening (46.1% for TBC vs 24.1% for TPM; odds ratio OR, 1.91 95% CI, 1.75 to 2.08), adherence to a diabetes care bundle (24.6% for TBC vs 19.5% for TPM; OR, 1.26 95% CI, 1.11 to 1.42), and documentation of self-care plans (48.4% for TBC vs 8.7% for TPM; OR, 5.59 95% CI, 4.27 to 7.33), lower proportion of patients with controlled hypertension (<140/90 mm Hg) (85.0% for TBC vs 97.7% for TPM; OR, 0.87 95% CI, 0.80 to 0.95), and no significant differences in documentation of advanced directives (9.6% for TBC vs 9.9% for TPM; OR, 0.97 95% CI, 0.91 to 1.03). Per 100 person-years, rates of health care utilization were lower for TBC patients compared with TPM patients for emergency department visits (18.1 for TBC vs 23.5 for TPM; incidence rate ratio IRR, 0.77 95% CI, 0.74 to 0.80), hospital admissions (9.5 for TBC vs 10.6 for TPM; IRR, 0.89 95% CI, 0.85 to 0.94), ambulatory care sensitive visits and admissions (3.3 for TBC vs 4.3 for TPM; IRR, 0.77 95% CI, 0.70 to 0.85), and primary care physician encounters (232.8 for TBC vs 250.4 for TPM; IRR, 0.93 95% CI, 0.92 to 0.94), with no significant difference in visits to urgent care facilities (55.7 for TBC vs 56.2 for TPM; IRR, 0.99 95% CI, 0.97 to 1.02) and visits to specialty care physicians (213.5 for TBC vs 217.9 for TPM; IRR, 0.98 95% CI, 0.97 to 0.99, P > .008). Payments to the delivery system were lower in the TBC group vs the TPM group ($3400.62 for TBC vs $3515.71 for TPM; β, -$115.09 95% CI, -$199.64 to -$30.54) and were less than investment costs of the TBC program.
Among adults enrolled in an integrated health care system, receipt of primary care at TBC practices compared with TPM practices was associated with higher rates of some measures of quality of care, lower rates for some measures of acute care utilization, and lower actual payments received by the delivery system.
We investigate the effects on health care costs and utilization of team-based primary care delivery: Quebec’s Family Medicine Groups (FMGs). FMGs include extended hours, patient enrolment and ...multidisciplinary teams, but they maintain the same remuneration scheme (fee-for-service) as outside FMGs. In contrast to previous studies, we examine the impacts of organizational changes in primary care settings in the absence of changes to provider payment and outside integrated care systems. We built a panel of administrative data of the population of elderly and chronically ill patients, characterizing all individuals as FMG enrollees or not. Participation in FMGs is voluntary and we address potential selection bias by matching on GP propensity scores, using inverse probability of treatment weights at the patient level, and then estimating difference-in-differences models. We also use appropriate modelling strategies to account for the distributions of health care cost and utilization data. We find that FMGs significantly decrease patients’ health care services utilization and costs in outpatient settings relative to patients not in FMGs. The number of primary care visits decreased by 11% per patient per year among FMG enrolees and specialist visits declined by 6%. The declines in costs were of roughly equal magnitude. We found no evidence of an effect on hospitalizations, their associated costs, or the costs of ED visits. These results provide support for the idea that primary care organizational reforms can have impacts on the health care system in the absence of changes to physician payment mechanisms. The extent to which the decline in GP visits represents substitution with other primary care providers warrants further investigation.
Centers of excellence-specialized programs within healthcare institutions which supply exceptionally high concentrations of expertise and related resources centered on particular medical areas and ...delivered in a comprehensive, interdisciplinary fashion-afford many advantages for healthcare providers and the populations they serve. To achieve full value from centers of excellence, proper assembly is an absolute necessity, but guidance is somewhat limited. This effectively forces healthcare providers to pursue establishment largely via trial-and-error, diminishing opportunities for success.
Successful development of a center of excellence first requires the acquisition of a detailed understanding of the delivery model and its benefits. Then, concerted actions must be taken on a particular series of administrative and clinical fronts, treating them in prescribed manners to afford synergies which yield an exceptionally high level of care. To reduce hardships associated with acquiring this rather elusive knowledge, remedy shortcomings in the literature, and potentially bolster community health broadly, this article presents information and insights gleaned from Willis-Knighton Health System's extensive experience assembling and operating centers of excellence. This work is intended to educate and enlighten, but most importantly, supply guidance which will permit healthcare establishments to replicate noted processes to realize their own centers of excellence.
Centers of excellence have the ability to dramatically enhance the depth and breadth of healthcare services available in communities. Given the numerous mutual benefits afforded by this delivery model, it is hoped that the light shed by this article will help healthcare providers better understand centers of excellence and be more capable and confident in associated development initiatives, affording greater opportunities for themselves and their patient populations.
This book mounts a critique of current health economics and provides a better way of looking at the economics of health and health care. It argues that health economics has been too dominated by the ...economics of health care and has largely ignored the impact of poverty, inequality, poor housing, and lack of education on health. It is suggested that some of the structural issues of economies, particularly the individualism of neo liberalism which is becoming more and more pervasive across the globe, need to be addressed in health economics. The author instead proposes a form of collective decision making through communitarianism, placing value on participation in public life and on institutions, such as health care. It is envisaged this form of decision making can be used at the local, national or global levels. For the last, this would mean a major revamp of global institutions like the World Bank and the IMF. Examples of the impact of the new paradigm on health policy in general but also more specifically on priority setting and equity are included. Available in OSO: http://www.oxfordscholarship.com/oso/public/content/economicsfinance/9780199235971/toc.html
This is an exciting time in East Asia and the Pacific region. No region will appear to be moving so rapidly. In this dynamic environment, many countries in the region have been approaching the World ...Bank requesting technical assistance and knowledge about health financing best practices and options. There is great interest in expanding knowledge sharing and learning from other East Asian and Pacific countries about their experiences in health financing. Moreover, some common issues appear to be emerging: universal insurance, options for financing health insurance, institutional setups of health financing options, provider payment mechanisms, equity considerations, ways to reach the poor and impoverished, and ways to meet the challenges of a changing demographics and epidemiologic profile. Under a generous grant from the Health, Nutrition, and population hub in the World Bank in fiscal year 2008, the region was requested to provide an overview of health financing systems in the region. This overview examined the different health financing mechanisms in terms of performance on dimensions of efficiency and equity and in terms of relative roles of government. In addition, the analysis was to identify, gaps in knowledge needing to be addressed strengthen and reform existing health financing mechanisms and thereby expand health coverage and benefits.
Health systems are employing physicians in growing numbers. The implications of this trend are poorly understood and controversial. We use rich data from the Centers for Medicare and Medicaid ...Services to examine the effects of a set of physician acquisitions by hospital systems on outpatient utilization and spending. We find that financial integration systematically produces economically large changes in the acquired physicians’ behavior, but has less consistent effects at the acquiring system level.
No other country has undergone health care reforms as dramatic as China's. Starting in 1978, China reformed its health system from a governmental, centrally planned, and universal system to a heavily ...market-based one. Now, three decades later, the Chinese government openly acknowledges that the reforms failed and seeks new directions. This paper adds to the literature by examining China's health care from a system perspective, describing its health services delivery, access, outcomes, and population health in the post-reform era. It also identifies the main issues in the current system and highlights the key lessons learned from China's reform process.
Quality circles or peer review groups, and similar structured small groups of 6-12 health care professionals meet regularly across Europe to reflect on and improve their standard practice. There is ...debate over their effectiveness in primary health care, especially over their potential to change practitioners' behaviour. Despite their popularity, we could not identify broad surveys of the literature on quality circles in a primary care context. Our scoping review was intended to identify possible definitions of quality circles, their origins, and reported effectiveness in primary health care, and to identify gaps in our knowledge. We searched appropriate databases and included any relevant paper on quality circles published until December 2017. We then compared information we found in the articles to that we found in books and on websites. Our search returned 7824 citations, from which we identified 82 background papers and 58 papers about quality circles. We found that they originated in manufacturing industry and that many countries adopted them for primary health care to continuously improve medical education, professional development, and quality of care. Quality circles are not standardized and their techniques are complex. We identified 19 papers that described individual studies, one paper that summarized 3 studies, and 1 systematic review that suggested that quality circles can effectively change behaviour, though effect sizes varied, depending on topic and context. Studies also suggested participation may affirm self-esteem and increase professional confidence. Because reports of the effect of quality circles on behaviour are variable, we recommend theory-driven research approaches to analyse and improve the effectiveness of this complex intervention.
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